Concise Guidelines of the European Cardiac Arrhythmias Society (ECAS) on “Catheter Ablation of Atrial Fibrillation”

• DOI: 10.1111/jce.16561
• Publication Date: 2025-03-09T03:21:58Z
• Authors: Riccardo Cappato; Samuel Levy; Rui Providencia; Hussam Ali; Andrey Ardashev; Sergio Barra; Antonio Creta; Michal Farkowski; Christian‐Hendrik...; Prapa Kanagaratnam; Thorsten Lewalter; Silvia Magnani; Richard Schilling
• Keywords: Cardiac Ablation

Guidelines have been introduced to provide "systematically developed statements assist practitioner and patient decisions about appropriate health care for specific clinical circumstances" [1]. Since their introduction, they a valuable tool large population of stakeholders, including physicians, patients, hospitals, educational bodies, manufacturers, providers insurers in medicine. While guidelines are meant help professionals taking routine decisions, there very few studies possessing the quality required generate solid recommendations. Despite limited high-quality evidence, typically consist full-bodied texts tables reporting extensive lists recommendation [2-4]. To compensate lack evidence-based documentation, incomplete condensed judgment among authors used recommendations intermediate class enriched with sub-categorization based on multiple arbitrarily generated "levels evidence". Frequent updating produced by different scientific bodies adds model complexity. In addition, increasingly perceived as creating unjustified legal liability practitioners despite evidence which based. address this, processes proposed impose rigor transparency guideline documents [5, 6] assess guidelines, methodological strategy development, clarify what information how this should be reported [7, 8]. As result, contract volume re-direct focus indications supported more evidence. Criteria adopted substantiate need our described paragraphs "Criteria Class I, II III recommendations" Chapter 5. Catheter ablation AF represents situation rather limited. Yet, consensus resulted production copious [2-4, 9]. With intent producing that serves its intended purpose reconciling art medicine, European Cardiac Arrhythmia Society (ECAS) proposes concise coordinate document field. ECAS is an independent society founded 2004 Paris mission promote discipline better diagnosing treating cardiac arrhythmias. The criteria define classes summarized paragraph "criteria below. This Guideline was registered PREPARE (Practice Registration transparency; registration number: PREPARE-2024CN005) February 2024. Multiple searches randomized controlled trials inform were performed. These done part purpose-built systematic reviews meanwhile published separate manuscripts present detailed search strategy, PICO approach questions addressed each Reviews. Randomized meeting inclusion included. Additionally, not addressing other aspects covered reviews, but identified through process also considered eligible [10]. An update planned, definition starting, up 5 years following publication date document. earlier may occur, if justified, driven novel technology or impactful field such circumstances, decision only section guideline, than whole "The logic science hypothetical. powerful, turn back incontrovertible thruth. No matter strong degree confirmation, hypotheses can 'falsifiable' at any time" [11]. Definition truth has subjected considerable modifications over time [12]. 2nd century A.C., Ptolemy cosmologic according earth would stand motionless center universe. It took 13 centuries before Copernicus new, revolutionary supporting concept rotate around sun one theory became widely accepted [13]. era, technological development accelerates progress communication. even when created using science, become out quickly. Therefore, it inevitable current methods will reviewed changed future. universal adoption medicine recast medical knowledge way experimental designed validate single isolated interventions take highest status and, so doing, undermine lock place reductive disease [10, 13]. document, solely reference point management AF. consistent societies preparation taken under assumption new paradigms surface future offer base theories, investigation validation subvert guideline's structure. First old French speaking derivation Medieval Latin recommendationem (nominative recommendatio), word "act representing (something) favorable manner, act recommending (someone something) worthy" [14]. early days, lost original meaning escalated level close imperative statements. At present, tend refer persuasive obligations response feel bound behave irrespective robustness source data. Accordingly, controversies practitioners' behavior resolved resorting ultimate form judgment. We argue continue reflect selected manner" obligations. representation apply conditions substantiated documentation arbitrary reflected further experts. keeping these aims, we propose linear scheme creation. guided previously believe best suits serving community while preserving significance term assist, care; proportion consistency most disciplines; from dominant documents; expert unstudied, levels, introducing arbitrariness final decisions; limitations above amplified obtained gray areas knowledge; limitations, dedicated instruments being favor production. technique PVs electrical isolation, first Haissaguerre et al. [15, 16], four fundamental purposes: (1) does require ongoing successfully accomplished [16]; (2) segregates all arrhythmogenic foci local circuits within PV muscular layers possibly precipitating sustained episodes [16] (3) reduces overall mass electrically active atrial tissue (4) provides highly reproducible consistently verifiable setting EP procedure [15]. introduction 2000, global scale qualifying mandatory catheter type (i.e., paroxysmal, persistent long-standing persistent). isolation achieved energy forms (RF [16, 17], CB [18, 19], Laser [20-22], PF [23, 24]) designs (single tip [17], balloon [20, 21], basket-flower [24]). segregation effective variable proportions patients AF, outcomes cannot predicted individual patient. Two factors likely contribute observation: recurrent PV-to-left atrium conduction across isolating line days/months after nominal [25] location outside segregated area [25]. cases, stability lesions means procedures [26]. efficacy establishing stable appear dependent design [24, 27, 28]. Evidence arrhythmia indicates triggers precipitation must originate non-segregated [29]. Complimentary ablate areas, ganglionated plexi [30] spontaneous catecholamine-elicited [29, 31, 32], ethanol infusion ligament Marshall [33] LAA (LAA) [34, 35]. case foci, opportunity ectopic beats course [32]. techniques awaits especially light of: inability accurately identify effectively [30]; sporadic prevalence spontaneously occurring [31]; non-clinical nature drug-induced arrhythmias [32]; 4) standardized enabling accurate evaluation acute extra-PV [31]. rationale lesion intention replicate compartmentalization (MAZE procedure) surgery late 90 s [36]. consists point-by-point deployment pulses until continuous (transmural) constructed between two anatomical boundaries offers three potential advantages: deployed sinus rhythm well during AF; enables without open-heart surgery; option "customizing" special ability deploy makes appealing spite benefit, failed prove several [37]. Conversely, associated increased propensity macro-reentrant tachycardias follow-up [38]. circumstance undesired effect commonly related recurrence gaps along CFAE stems hypothesis localized critical enable maintenance paroxysmal "functional" re-entry-dependent mechanism [39]. recording those same sites fails show abnormal potentials. functional character re-entrant circuit outlined fluctuations, albeit limited, position morphology [40]. Ablation delivered where CFAEs electrogram reproducibility beyond 5–8 [41]. According model, responsible some lead termination episodes, preclude severely factors. Among them are: definitions investigators [40, 41]; durations analysis tested re-iteration signal) depending manual computer-assisted algorithm used; automatic detection algorithms incorporated various computer-assisting tools available lab 41] More substantially, geographically conflicts multi-wavelet multi-layer activity shown monitoring human beating hearts. Clinical experience inconsistent. promising data study [39] replicated elsewhere use scale. Rotors 1990 [42] phase singularities anatomically identifiable atria episodes. theory, regions extreme wave curvature reentry velocity approximates zero detected mapping [43]. rotors simultaneously leading distal wavefront collision, thus contributing appearance disorganization. Phase phases depolarization/repolarization cycle exist important because capable steadily. computational modeling [44], 3D allowed identification structure singularities, termed filament, spanning endocardium epicardium configurations (I, U O). Clinically, tangible feature rotor repetitive, cyclic activation core [45, 46]. simplest visual criterion identifying maps (FIRM) isochronal images, capture essence detecting defining rotor. result Given impact presentation plays therefore, ablation, valid classification type. Of many models proposed, purposes appears temporal duration [47]. into terminates spontaneously, AADs, 7 days onset), no longer 1 year susceptible successful cardioversion) AADs) simple intuitive, noted categorization groups always easy, episode vary symptomatic. individual, fall category view another [48]. Similarly, dissociation AF-type pathophysiologic background substrate fibrosis) documented [49]. recognize value ideally characteristics referenced studies. Because differ sub-category (paroxysmal, persistent), list references indicating contributed scheme. studies, readers find provided authors. reader's whether strictly sources, applicable similar identical presentations. Classes I–III Tables 1–3, respectively. Flowcharts showing indicated below Figures 1-3, 3b. Supporting Information: S1–S3 complimentary number enrolled, randomization ratio S4, S5a, S5b alternative S1, S2a, S2b, S3a, S3b, focusing primarily technologies obtain designated outcomes. Information material literature contributions basis research (pages 24–54). selection Compilation made against unaddressed changes programmed edition guidelines. outcome results extended 12-month duration, applicable. greater benefit risk safety profiles comparative low Risk Bias crucial domains [71] high precision expressed narrow 95% confidence interval [72] absence contradicting compliance principle directness, comparability investigated trial directed [72]. Finally, multi-center ensure representativeness Failure comply down-grading practice, (Table 1). drug-refractory RF superior AADs reducing suppressing recurrences onset, AADsa (i.e. 24 months documentation) preventing progression CHF reduced EF, long-term mortality re-hospitalization improving Quality Life similarly 2-min 4-min Cryo-ballon burden pre-determined working hypothesis; insufficient sample size; well-designed prematurely terminated futility failure enroll anticipated population; targeted meta-analyses endpoints still available. Table S2 justifications qualify technical/technological S3–S5 indicate custom-made relative indication 2). onset) adding vein symptomatic end-stage heart guideline-directed therapy all-cause death, implantation left ventricular device urgent transplantation psychological symptoms anxiety depression low-voltage voltage stroke§ reduce hospitalization improve LVEFb RF, dual-energy procedural failure, recurrences, drug initiation escalation cardioversion practice harm overweighting 3), derived multicenter adopting sufficient sizes (Figures 3a,b). MRI-guided fibrosis higher death ablating fractionated EGs recurrencesa posterior wall isolationto ligation appendix epicardial clip system A recently schemes ESC, ACC/AHA/ACCP/HRS EHRA/HRS/APHRS/LAHRS S6. There body investigating role supplementary lesion, ablation. [74], electrograms [39], [75] [76] do recurrences. Thus, fulfill I requirements strategies generic, size fits approaches. therapeutic behind possible reasons addition discussed 3. Overall, 10 RCTs 2005 2017 (Supporting S3) [74, 77-85]. Five [77-81] enrolling aggregate 643 non-paroxysmal 2008, compared roof and/or mitral isthmus ostial segmental (early technique) only. trials, showed remaining 82-85] conducted 2011 1000 whom majority note, latter performed WACA. All report lesion-induced integrity. Procedure radiation exposure significantly receiving whereas complication rates did groups. meta-analysis group assure confirmed (but generic non-selective) Figure S6). 8 2015 1312 86-92] S8). them, 3 versus only, not. [91], incidence tachycardia flutter differences found respect complications. Most automated software-guided target site dv/dt intrinsic deflection mean length < 120 ms s), replace process. approaches fail integrate less defined attributes averaging relationships surrounding electrograms. Other poorly parameters included EG source, catheter, electrode orientation contact force. 1415 confirms supplemental (generic non-selective variably defined) [93]. 4 almost pts 2009 2022 [94-97] S5. seminal RCT 242 freedom PVI lower + GPA [94]. 264 persistent/long-lasting undergoing who additional LA GPA, implanted ILR. During 3-year follow-up, [95]. However, centers, though observational retrospective suggested beneficial effects [98]. selective triggering-GP alone, occurrence pericarditis requiring [96]. Surgical increasing risks major bleeding pacemaker due node dysfunction [97, 99]. Several interpretation addressed. uniform localizing gangliona